Patricia L. Hale, MD, PhD, FACP
CMIO, Glens Falls Hospital and CTO , Adirondack Regional
Community Health Information Exchange
pathale@pathalemd.com
www.pathalemd.com
Learning Objectives
 Impact of e-prescribing on patient safety and
reduction of medication errors
 What’s new
 Explore the training requirements for physicians
 Explore the implementation differences between
a small medical practice and an RHIN
7,000 Americans Die Annually
From Preventable Medication Errors
1.5 Million Americans Injured Annually
by Preventable Medication Errors
Source: The Institute of Medicine of the National
Academies of Science (IOM).2006
Slide used by permission from SureScripts
The Challenge of “Prescription Hand-offs”
•
Illegible Handwriting
Physicians write
•
Unclear Abbreviations and Doses
4.5 billion prescriptions
•
Verbal Communication Among
Physicians, Patients and Pharmacists
each year. . . .
On Paper!
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Over 4.5 Billion Prescriptions Written Annually…
Less than 1 in 5 of Physicians Use e-Prescribing
Only 20% of prescriptions are prescribed
electronically with 80% still handwritten
Most electronic prescriptions are still sent by FAX
National savings from universal adoption of
electronic prescribing systems
could be as high as $27 billion
Sources: eHealth Initiative, 2004 and: Center for Information Technology Leadership, “The Value of
Computerized Provider Order Entry in Ambulatory Settings,” 2003.
Rx
Rx
Patient safety


Between 1.5%-4.0% prescriptions
are in error with serious patient
risk
Adverse drug events occur in 5%18% of ambulatory patients
Quality of care - Compliance


20% of scripts are never filled
Patient satisfaction is declining
Cost of errors: $2 billion / year
Impact on productivity*

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
Physician practice: 3 hours per day
Pharmacy: 4 hours per day (up to 1
call per Rx)
Inefficient delivery
Rx



Illegible
handwriting
Phone tag and
fax tag
Patient waiting
in the pharmacy
Unfilled

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
1)
2)
3)
823 million visits to
physician offices in 20001
4 out of 5 patients who visit
a physician leave with at
least one prescription2
65% of the US population
(91% of Medicare) use a
prescription medication
each year3
0.4 B
Renewals
0.5 B
1.5 B
Refills
1.4 B
New Scripts
3.5 Billion Total Filled Prescription
Transactions in 2003 increased to 4.5 in
2006
Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, 2002. National Center for Health Statistics. 2002.
The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001.
Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999.
Rx
InterOp
150,000 Certified EMR Users


Certified version typically a
simple upgrade away
Extremely low awareness
among install base
Practice
Size
Best estimates for EMR
adoption based on high
quality surveys (%)
All
24
Solo
16
Large*
39
*”Large” is defined as > 20 physician FTEs in one
study with 39% adoption and >50 in two another
studies with 47% and 57% adoption respectively.
Sources: Jha et al, Health Affairs, 10/11/06; MGMA, 2005; CDC/NCHS Nat’l Ambulatory Medical Care Survey, 2005; HSC
Community Tracking Study, 2006; Forrester, 2003; SureScripts estimates, 2006. Slide used by permission from SureScripts

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Ability to create a prescription electronically
Ability to receive automated decision support during script
creation
 Medication lists and information
 Eligibility determination
 Formulary coverage from insurer including co-pay information
 Prior authorization
 clinical decision support including Drug interactions, drugallergy, etc.
Ability to send script electronically to pharmacy using standard
transmission messaging (NCPDP SCRIPT, ASC12)
Ability to receive/authorize pharmacy initiated-renewals
electronically
Ability to determine “fill status” as a measure of compliance
(medication history)
Ability for pharmacy to process electronic script in their system
Slide used by permission from SureScripts
Prescriber
eRx
Software
ProxyMed and others
SureScripts Provides:
Pharmacy
and PBM
eRx Software
New Rx, refills, renewals,
authorizations, change
Rx, Prescription history
from pharmacies
Medimedia
and others
RxHub Provides: Eligibility, Formularies, medication claims histories
Minutes per day
Prescribers
(2006 Study: Brown University)
Office staff
Slide used by permission from SureScripts
Pen
Print
6%
Fax
37%
EDI
+
Decision
Support
61%
Source: CITL
Slide used by permission from SureScripts
<5%
16-40%
40-80%
Patient &
Physicians
Access
Medical
Websites
7-20%
Electronic
Prescribing
Electronic
Medical
Records
Systems
Regional
Health
Information
Networks
National
Health
Information
Infrastructure
National
Disease
Databases
“EvidenceBased”
Medicine
Increased Decision Support
 Algorithm-driven
 Population Gains in
 Better informed
consumers
accuracy and
connectivity
enhance safety
and efficiency
 Integrated
database allow
decision
support tools
 Streamlined
information
retrieval:
valuable for
epidemiology
based outcomes
and cost
information
readily available
to consumers,
physicians,
payers
medicine and
decision making

Patients:
 Increased safety, efficiency and compliance
 Lower co-pays

Pharmacies:
 Increased efficiency, improved care, improved patient
satisfaction

Payors/PBMs:
 Increased generic/formulary usage, efficiency, Rx
compliance and prevention of ADEs (reduced costs)

Providers:
 Increased efficiency, improved care, patient satisfaction and
potential incentives (pay-for-performance)

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Cost of buying, installing, implementing and
supporting a system
Lack of reimbursement for costs, time and
resources
Increased time to use the system = reduced
productivity (initially)
Increased time required to review warnings,
alerts and recommendations (long term)
Still not considered a routine standard of practice
In the past…
But now…
Very few pharmacies were directly connected to
physician practices
Over 95% of US pharmacies are connected into
a single network and growing
Electronic communications meant faxes
Computer applications can communicate directly
with each other
Only half the problem was being addressed…
writing new scripts
Renewals can be automated in addition to new
scripts
Software didn’t support the workflows in the
practice
Software integrates with existing practice
systems and smoothes office workflow
There were few real benefits for most practices
Most practices will save physician and staff time
as well as improve patient safety
There wasn’t a future path to additional benefits
Collaboration now available with payors on
patient compliance and other future functions
Automation was being driven by a few Health
Plans and small software vendors
State and nation-wide initiatives now occur
involving all major stakeholders

Economic Incentives

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
Grant and Loan Programs
Reimbursement for Utilization
Pay for Performance
Malpractice Insurance Premium Reductions
Healthcare IT Suppliers group discounts, etc
Pharmacies or Transaction Brokers Defray Costs
Policy Incentives and Programs
 Accreditation (JCAHO 2005 Hospitals’ National Patient Safety Goals,
others in development)
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Employer Programs (Leapfrog and others)
Medicare support for economic incentives
DOQ-IT
CCHIT certification of inpatient and ambulatory EMRs
Mandates ???


Voluntary program
Mandatory National eRx Standards for Medicare
 Initial standards 2005; Pilot program 2006, Final Standards 2009
 Recommendations delivered by NCVHS

Information Requirements include
 Lower cost, therapeutically appropriate alternatives
 Interactive, real-time to the extent feasible

Encourages Physician Adoption:
 Permits use of appropriate messaging
 Modifies anti-kickback regulation for hospital, physician groups and plan
administrators to allow them to give out eRx hardware and training
 Allows plans to pay-for-technology and pay-for-cost effective
performance in Medicare Advantage Plans
 $50MM of federal grant money in 2007 (but must be budgeted)

Preempts State Laws contrary to the national standards or
those that restrict the ability to carry out the new law.

Progress-to-date
 Issued Notice of Proposed Rule-Making (10/05)
 Issued final rule naming foundation standards (11/05)
 Pilot programs competed and reports submitted (2/06)
Deadline for
Secretary to
develop
ePrescribing
Standards
Sept 1, 2005
Launch 1-yr
voluntary
ePrescribing
pilot program;
plans can offer
P4P
Jan 1, 2006
Evaluation
results of pilot
program due to
Congress
Apr 1, 2007
Deadline for
Secretary to
finalize and
release
standards
Apr 1, 2008
All Medicare
providers using
ePrescribing must
adopt finalized
standards
April 2009
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RAND – New Jersey BCBS NJ, Caremark mail order, Walgreen
retail pharmacy
Brigham & Women’s Hospital - CareGroup Health system in
Boston use in EMR and e-prescribing “Gateway” utility
Achieve – tech vendor for long term care industry in Midwest
with it’s own pharmacies
Ohio University Hospital Health System and Ohio KePRO
QIO - 300 hospital physician practices
Surescripts - with practices in Florida, Mass, Nevada, New
Jersey and Tennessee with a variety of software vendor
systems and assortment of chain and independent
pharmacies
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Med History – recommended to be included as ready for
adoption. Main challenge is ensuring the data is collected and
reconciled from a large number of sources to be sure history is
complete.
Formulary and Benefits – recommended to be included as
ready for adoption. Issues:
 Systems must adequately match patient to health plan
 Payers vary in the level of information provided making
data difficult to interpret
 Should support real-time changes in patient status as
patient moves between benefit plans

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Prescription Fill Status Notification – recommended to be
included as ready for adoption. However many pharmacies do
not currently have the ability to track patient pick-up status
accurately and questionable prescriber demand for this if the
info is already available in the med history.
Prior Authorization – NOT recommended for implementation
– Limited experience at pilot sites to evaluate this function and
there are work flow and other issues which suggest a need to
have more work done to improve the standard.
Structured and Codified Sig - NOT recommended for
implementation – needs additional work with reference to
field definitions and examples as well as naming conventions
and clarification of field use.
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RxNorm – (standard for name, dose and form of
drugs) – Not recommended for implementation –
Dictionary standard requires further evaluation
and refinement.
Recommended updates to SCRIPT v8.1 – Need to
further refine the standard to be able to:
 update prescriptions without having to create a new
order,
 send a refill from the facility to the pharmacy without
physician intervention,
 update patient information outside the context of
prescriptions
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Prescriber staff (“surrogate prescribers”) played a much
more important role in the process than anticipated.
Never fully replaces need for paper-based prescribing
Causes a shift in pharmacy work flow
Poor adoption and use of medication history
Long term care site reported a reduction in new
prescription rate which may indicate reduction in
accumulation of multiple medication
Not enough data yet on effects on safety or change in use
of generic medications.
The National ePrescribing Patient Safety Initiative
(NEPSI)
A Coalition of the Nation’s Most Prominent Technology Companies,
Healthcare Benefit And Medical Provider Organizations
“Dedicated to improving patient safety by providing free
electronic prescribing for every physician in America”
Slide used by permission from NEPSI
National Sponsors
Technology Sponsors
Health Benefit Sponsors
Search Sponsor
Connectivity Sponsors
The “ATM of Healthcare??”

eRx NOW™ from Allscripts described as:
 Simple: Web-based E-prescribing Software

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

Easy To Install and update
Easy Interoperability
Custom search engine from Google
Formulary information available
 Safe
 Comprehensive Allergy and Drug Interaction Checking
 Secure
 Secure anytime, anywhere access
 Rigorous credentialing and authentication
www.nationaleRx.com
Slide used by permission from NEPSI
Slide used by permission from SureScripts
Slide used by permission from SureScripts
Pharmacy Health Information Exchange™,
operated by SureScripts®
E-Prescribing E-Refills
Rx History
Eligibility
Formulary
Slide used by permission from SureScripts
Company
Product
System
Type
A4 Health Systems
Healthmatics® EMR
Allscripts
TouchWorks/ TouchScript
EP/EMR
Allscripts/NEPSI
eRx NOW™
EP/EMR
ASP.MD
ASP.MD
EMR
athenahealth
athenahealth
EMR
Axolotl
Axolotl
BCBS/AL
InfoSolutions
BMA Enterprises
Chart Management System
EMR
Bond Medical
BondMedical, Inc
EMR
Cerner
Community Health Record
ChartConnect
MedManager
DAW Systems
ScriptSure
EP
DrFirst
DrFirst Rcopia
EP
eClinicalWorks, Inc.
eClinicalWorks
EMR
E-Prescrib.
E-Refills
Rx History* Formulary* Eligibility
EMR
EP/EMR
EP
EP
EP/EMR
Slide used by permission from SureScripts

GoldRx certification status
 No longer based on just compliance to standards
 Identifies which vendors are not just testing and
marketing interoperability but are truly delivering
and committed to:
 Customer Education
 Proven Pharmacy Interoperability
 Advanced Medication Management
 Workflow Enhancements & Demonstrable
Expert Experience with Electronic Prescribing
Process
Slide used by permission from SureScripts

The first products to achieve
GoldRx certification
announced in Feb 2007:
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TouchWorks EHR(Allscripts)
ChartConnect EMR
Rcopia (DrFirst)
NextGen EMR
eScript (RelayHealth)
Pocketscript (Zix)
Slide used by permission from SureScripts
Created by the National
Association of Chain Drug
Stores, the National
Community Pharmacists
Association and SureScripts
Last Year: RI was #1, MA was
#3, MI was #10, WA and NJ not
on last years list and FL and VA
were in last year’s Top 10
Slide used by permission from SureScripts
Certification Commission for Health Information
Technology (CCHIT)
CCHIT Certification EMR ePrescribing Criteria
2007
2008
2009
l
Send an electronic prescription to pharmacy
Send a query for formulary information
l
Send a query for medication history to PBM or pharmacy
and import medication list into EHR
l
Respond to a request for a refill sent from a pharmacy
l
Receive medication fulfillment history
l
Respond to a request for a prescription change from a
pharmacy
l
Send a cancel prescription message to a pharmacy
Send electronic prescription to pharmacy including
structured and coded SIG instructions
l
l
RxHub
SureScripts
Source of Data
Claims data from
PBMs
Dispensed Drug Data
from Pharmacies
Interoperability
Model
Pass-through
Repository
Details Included
No sig
Sig (unstructured)
Regional Coverage
Plan dependent
Pharmacy dependent
Pricing
$$$
$
44
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A4 Health
Achieve
Allscripts
Athena Health
Bond Medical
Catalis Health
Cerner
DrFirst
eClinical Works
eHealth Solutions
EmDeon/WebMD
EPIC
Gold Standard
H2H Solutions
Health Vision
Bold = in production
47
 InstantDx
 OA Systems
 iScribe
 Phytel
 MA Share
 Purkinje
 McKesson
 Relay Health RxNT
 MDAnywhere
 SafeMed
 MdOffices
 Script IQ
 Medical Info Sys
 ScriptRx
 MedicWare
 Scriptsure
 MedKeeper
 Sequel Systems
 MedPlus
 SSIMED
 Medport
 STI Con
 NewCrop
 Synamed
 NextGen
 Zix Corporation
Health care professionals can register for an
ICERx.org account at www.ICERx.org or call
1.888.ICERX.50 (888-423-7950).

During periods of emergency, licensed health care
professionals who have registered on ICERx.org
can login to the online prescription database,
where they will have access to:
 Evacuee prescription history information and the
name of the provider who wrote the prescription and
the pharmacy that filled it
 Available patient clinical alerts, including drug
interaction, therapeutic duplication and elderly alerts
 Clinical pharmacology drug reference information,
including drug monographs, interaction reports and
the drug identifier tool
As of February 2nd, 2004 - 25 States
cleared for electronic prescribing
As of February 2nd, 2007 - 48 States and
Washington, D.C. cleared for electronic prescribing
Slide used by permission from SureScripts
52
Not shown: HI: 42%; AL: 24%; As of November 9, 2006

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Access to more than 160 million patient prescription information
records via payers and PBMs, through the growing list of RxHub
certified technology partners. Direct contracts with payers and PBMs
represent additional access to more than 50 million patients.
An increase in transaction volumes of 50% from 29 million
transactions in 2005 to more than 43 million transactions in 2006. These
transactions were real-time requests for patient eligibility and benefits,
formulary, and medication history information, made at the point-ofcare in the ambulatory and acute care settings from clinicians across the
United States.
A ten-fold increase in true electronic prescriptions, which includes the
transmission of patient-specific clinical decision support information at
the point of prescribing, to retail and mail order pharmacy locations of
the patient’s choice.

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No two medical practices are alike – evaluation
of current processes is critical in determining
best product and implementation plan
Physicians learn by apprentice model – be sure
there is a physician champion
Evaluate requirements for physician training
early and plan schedules to accommodate
decreased productivity
Workflow is a critical factor in success


Staff roll in the prescribing process is a major
influence on potential success and usually
underestimated
Time for training and implementation should be
maximized (consider vendor recommendations
as a MINIMUM)
When implementation of electronic prescribing is
through a regional health information network
new issues arise which include:
 Management of shared medication lists
 Management of shared problems lists
 Opportunity for aggregated medication history
data
 Increased concerns about secondary use of
prescriber data

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More options for stand alone, certified EMR and
information network based electronic prescribing
products
Increased connectivity of pharmacies and PBMs
Increased functionality to improve office efficiency
(electronic refills)
Support for implementation through programs like
DOQ-IT and others
Grant, P4P and other funding opportunities
New educational material and resources are available
“We tried dedicating this computer to deciphering our
doctors' handwriting."
Cartoon by Dave Harbaugh
Contact me at: pathale@pathalemd.com
Web site with further information and links:
www.pathalemd.com